Administration and Leadership

Reference Notes can Aid You en Route and on Scene

Issue 8 and Volume 39.

I’m sure I’m not the only person who wrote tiny, cryptic cheat sheets to get through the daily quizzes in French and Spanish classes. I say that because I compared mine to my classmates’ many times.

I was proud of mine because I developed them as I studied what would be on the quiz the next day. I would study a word and its meaning and then put the word and a 1–2- word “memory jogger” on the tiny piece of paper I would stealth between my legs so, if I drew a complete blank on a word, all I had to do was glance down and see a snippet of what the word meant.

Dyspneic patient with signs of heart failure

I can still vividly remember getting caught looking down at my crotch reference sheet one day by my Spanish teacher, Bobby Bischio. I must’ve been overtly looking down for too long and, the next thing I knew, Mr. Bischio snuck up from behind and said, “Give me that!” while pointing at my crotch. Trying to be coy, I replied, “Give you what?”

He didn’t find my remark humorous and immediately sent me to the principal’s office with a note that said “Caught cheating during Spanish quiz.”

I can still remember the vice principal, Angelo Gentilezza—a tough no-nonsense Italian educator who knew my family well—reaming me for what seemed like an hour.

He explained to me that there was nothing wrong with keeping detailed notes for reference at a later time, but that the only way to train your brain for short term recall was to buckle down and study the important terms for the next day. I walked out of his office with my tail between my legs, but also as a better person for the scary encounter. It helped me learn how to properly take notes, how to study and how to label and use my notes when I went off to college and into the workforce.

I carried those habits as I studied during paramedic training years later. I took meticulous notes and then synthesized and color-coded them into quick-reference pages with my now-legendary highlighting formats. I used those condensed notes every three years to study and refresh my memory when I was required to recertify. There was no need for me to restudy how drugs affected the heart as long as I saw “ABCD” in my notes:

Alpha Beta Constrict Dilate

When I was doing a clinical rotation during paramedic training in 1977, an ED physician who was really interested in giving medical command to young paramedics showed me how he condensed our protocols into small checklists he carried in the pocket of his lab coat with a bunch of other sheets on pediatric drug dosages and other need-to-know reference points. When he was told a paramedic was calling in for consultation on a severe asthmatic, he would pull out his pocket checklist, flip to “asthmatic” and read it over while walking to the radio console.

He told me the full set of regional ALS protocols was at the console, but he only needed to see proper dosages and drug sequences to give us good orders. He then suggested I also make checklists and use them as a quick reference when responding to complex calls. This way, everything would be fresh in my mind and I wouldn’t be ashamed to reference them on scene to ensure I gave the proper care rapidly and without making possibly harmful or deadly mistakes.

I took it as good advice and created my own reference notes on small index cards I then carried in my shirt pocket on every shift. I rarely had to use them on scene because if I didn’t know something, I had already referenced them en route. (See photos, p. 12.)

Snohomish County's rapid sequence intubation checklist.

Page 2 of Snohomish County’s rapid sequence intubation checklist.

I dusted off those helpful memory joggers recently when we were editing June’s important article on the benefits of developing and using checklists in the field, titled “The Value of Checklists: We’ve had the solution all along.” In his article, Captain Shaughn Maxwell, EMT-P and medical services officer for Snohomish County (Wash.) Fire District 1, writes about the history, rationale and benefits of developing and using EMS checklists during responses to ensure evidence-based critical interventions are occurring when specific clinical conditions are encountered. His is an epic piece of work that earned him a 2013 EMS 10 Innovator Award from JEMS and Physio-Control.

What Shaughn and his medical director, Richard Campbell, MD, did was look at the most complex and often least used areas of their protocols, create checklists for those key areas and make them available to all ALS responders. The results of their program have been very positive, with many other departments around the country copying their innovative approach and implementing it in their own EMS service.

The fact is that we don’t often encounter cases requiring rapid sequence intubation, sepsis or carotid sinus massage. Checklists can play an important role in the resuscitation of these cases. They’re not cheat sheets, but rather important reference tools for our EMS toolkit.

More Admin & Leadership from